INTRODUCTION. CLI patients are at risk for limb loss and potentially fatal complications from progression of gangrene and development of sepsis.

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1 A RETROSPECTIVE STUDY ON LOWER EXTREMITY AMPUTATION LEVELS FOLLOWING ENDOVASCULAR REPERFUSION: AN INSTITUTIONAL REVIEW OF PODIATRIC MANAGEMENT IN THE LIMB SALVAGE TEAM Tyler Wishau, DPM; Jesse Wolfe, DPM; Matt Van Natta, MPH; Allen Jacobs, DPM, FACFAS; Robert Fischer, MD Sundeep Das, MD, FAAC; H. John Visser, DPM, FACFAS, FACFAO

2 INTRODUCTION CLI patients are at risk for limb loss and potentially fatal complications from progression of gangrene and development of sepsis. 1 Leg amputation due to PAD gives rise to 5-year survival rate of less than 30%. 2 Improvements in the process of early detection and appropriate treatment of patients with CLI are warranted. 1. Lumsden A, Davies M, Peden E. Medical and endovascular management of critical limb ischemia. J Endovasc Ther. 2009; 16(Suppl II):II Anahita D, Cheong LJ, Epidemiology of peripheral arterial disease and critical limb is ischemia. Tech Vasc Interventional Rad 2016; 19:91-95.

3 INTRODUCTION Multiple studies have demonstrated a reduction in both amputation and mortality among individuals diagnosed with CLI through instituting multidisciplinary limb-salvage teams. Vascular Surgeons Cardiology Infectious Disease Limb Salvage Team Interventional Radiology Endocrinology Podiatric Surgeons Sanders L, Robbins J, Edmons M. History of the team approach to amputation prevention: Pioneers and milestones. J Vasc Surg. 2010; 52:3S-16S Rogers L, Andros g, Caporusso J, et al. Toe and flow: Essential components and structure of the amputation prevention team. J Vasc Surg. 2010; 52:23S-7S. Kim P, Attinger C, Evans K, et al. Role of the podiatrist in diabetic limb salvage. J Vasc Surg. 2012;56: Chung J, G, Ahn C, et al. Multidisciplinary care improves amputation-free survival in patients with chronic critical limb ischemia. J Vasc Surg. 2015;61: Driverr V, GModrall oodman R, Fabbi M, et al. The impact of a podiatric lead limb preservation team on disease outcomes and risk prediction in the diabetic lower extremity.

4 PURPOSE Better understand the importance of podiatry in the limb salvage team, and to identify a correlation of amputation levels status post endovascular treatment with and without podiatry involvement. Vascular Surgeons Cardiology Infectious Disease Limb Salvage Team Interventional Radiology Endocrinology Podiatric Surgeons

5 METHODS Following IRB approval, a multi-center retrospective chart review was conducted using CPT codes and defining non-coronary angioplasty/stenting. CLI risk factors (ICD-9 codes): Diabetes ( ) Smoking (V15.82, 305.1) History of renal disease (443.9) Other demographics and risk factors will be identified and assessed for multivariate analysis using linear-regression modeling: Age, gender, renal-disease, obesity, atherosclerosis, gangrene, ulcerations.

6 METHODS 2,297 charts met initial inclusion CPT codes or 39.9 with no open bypass 1,545 charts excluded EVT unrelated to CLI Timing between diagnosis and treatment not quantified Mortality <1 year of EVT Less than 1 year follow up 752 patient charts were analyzed N=180 Yes PS Yes Amp N=261 Yes PS No Amp N=244 No PS No Amp N=67 No PS Yes Amp

7 PAD Risk Factors & Associated Outcomes Age Prior Hx of PAD Podiatry Y/N Gender Length of hospital stay Smoking Y/N Amputation Y/N Diabetes Y/N Final Level of Amputation

8 RESULTS Male vs Female Patients PS vs NPS 44% 41.3% 56% 58.7% Male Female Yes No

9 Percentage of Patients RESULTS % PS vs NPS with Amputation 80.00% 73.90% 60.00% 40.00% 20.00% 56.70% 43.40% 50.70% 27.80% 20.90% PS-A NPS-A 0.00% Diabetes Smoking PAD History

10 Percentage of Patients % RESULTS PS vs NPS Amputation-Free Patients 99.60% 80.00% 60.00% 40.00% 61.30% 36.50% 52.90% 40.20% 62.80% PS-NA NPS-NA 20.00% 0.00% Diabetes Smoking PAD Comorbidities

11 RESULTS Final Amputation Level Following Endovascular Treatment Between All Groups No Yes Major Minor

12 Number of Patients 160 RESULTS FINAL AMPUTATION LEVEL FOLLOWING EVT BETWEEN PS VS NPS GROUPS PS NPS Toe Midfoot BKA AKA Final Amputation Level

13 RESULTS Amputation + EVT Comorbidity Chi-Square Test (Two-sided; α=0.05) Odds Ratio (95% CI) Diabetes p< (n=752) OR=2.313 (1.677, 3.191) Smoking history Not Significant Not Significant Amputation + EVT Podiatry Chi-Square Test (Two-sided; α=0.05) Odds Ratio (95% CI) Podiatry Consult p<0.0001* 2.5 (1.805, 3.495) Podiatry Consult+Minor FAL p<0.0001* 105x (30.419, )

14 RECOMMENDATIONS ABI at age 50 in Diabetics Revasc. PAD & DFU Annual Exam with PAD Hx Hingorani A, LaMuraglia G, Henke P, et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. 2016; 63:3S-21S.

15 CONCLUSION A minor final amputation level correlated to PS consultation in patients status post EVT compared to patients without PS consultation The incidence of amputation was increased with PS consultation, but patients were significantly more likely to have a minor final amputation level with PS involved Smoking history (V15.82, 305.1) did not correlate to increased incidence of amputation following EVT PS inclusion in the limb salvage team offered CLI patients greater EVT success with respect to improved preservation of limb length

16 REFERENCES Lumsden A, Davies M, Peden E. Medical and endovascular management of critical limb ischemia. J Endovasc Ther. 2009; 16(Suppl II):II Anahita D, Cheong LJ, Epidemiology of peripheral arterial disease and critical limb is ischemia. Tech Vasc Interventional Rad 2016; 19: Dormandy J, Heeck L, Vig S. The fate of patients with critical limb ischemia. Semin Vasc surg. 1999; 12: Norgren L, Hiatt WR, Dormandy J, et al. Inter-Society consensus for the management of peripheral arterial disease (TASC II). Eur J Vasc Endovasc Surg. 2007; 33(suppl 1):S1-S75 5. Sanders L, Robbins J, Edmons M. History of the team approach to amputation prevention: Pioneers and milestones. J Vasc Surg. 2010; 52:3S-16S 6. Rogers L, Andros g, Caporusso J, et al. Toe and flow: Essential components and structure of the amputation prevention team. J Vasc Surg. 2010; 52:23S-7S. 7. Kim P, Attinger C, Evans K, et al. Role of the podiatrist in diabetic limb salvage. J Vasc Surg. 2012;56: Chung J, Modrall G, Ahn C, et al. Multidisciplinary care improves amputation-free survival in patients with chronic critical limb ischemia. J Vasc Surg. 2015;61: Driverr V, Goodman R, Fabbi M, et al. The impact of a podiatric lead limb preservation team on disease outcomes and risk prediction in the diabetic lower extremity. 10. Conrad M, Crawford R, Hackney L, et al. Endovascular management of patients with critical limb ischemia. J Vasc Surg. 2011;53: Conte M, geraghty P, Bradbury A, et al. Suggested objective performance goals and clinical trial design for evaluating catheter-based treatment of critical limb ischemia. J Vasc Surg. 2009;50: Rogers LC, Andros G, Caporusso J, et al. Toe and flow: essential components and structures of the amputation prevention team. J Vasc Surg 2010; 52(3 supple):23s-7s. 13. Hingorani A, LaMuraglia G, Henke P, et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. 2016; 63:3S-21S. 14. Sumpio BE, Armstrong DG, Lavery LA, et al., Society for Vascular Surgery, American Podiatric Medical Association. The role of interdisciplinary team appraoch in the management of the diabetic foot: a joint statement from the Society for Vascular surgery and the American Podiatric Medical Association. J Am Podiatr Med Assoc 2010;100: Krishnan S, Nash F, Baker N, et al. Reduction in diabetic amputations over 11 years in a defined U.K. population: benefits of multidisciplinary team work and continuous prospective audit. Diabetes Care 2008; 31: Sanders L, Robbins J, Edmonds M, et al. History of the team approach to amputation prevention: Pioneers and milestones. J Vasc surg 2010; 52:3S-16S. 17. Hioki H, Miyashita Y, Miura T, et al. Prognostic improvement by multidisciplinary therapy in patients with critical limb ischemia. J Angiology, 2015; 66(2): Vartanina S, Kristin D, Robinson K, et al. Outcomes of neuroischemic wounds treated by a multidisciplinary amputation preventions service. Ann Vasc Surg 2015; 29: Vinit N, Hogg, M Melina R, et al. Critical Limb Ischemia Review Article J Vasc Surg. 2010;